Surgery After Radiation

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I have heard that if I choose radiation therapy for prostate cancer treatment that I could not have surgery later if the cancer recurs. Why not?

Richard Whittington, MD, Associate Professor of Radiation Oncology at the University of Pennsylvania School of Medicine, responds:

There are few surgeons who will do prostatectomy after radiation therapy. The major problem is the fibrosis (scarring) caused by either surgery or radiation. It really does not matter what the first treatment is, the second treatment is typically always more difficult. After any surgery, it is much more difficult to do a second surgery in the same area because of the fibrosis from the first surgery. It is also more difficult to do surgery after radiation because of fibrosis.

In general, radiation causes more problems because there is more fibrosis in the region than there is after surgery. In contrast, it is easier to do radiation after surgery because we can do a CT scan to see and localize the intended target, and the radiation can penetrate through the fibrosis to get to the target. There is still an increased risk of complications, but it is not at much as the surgery-after-radiation option.

After radiation, a surgeon needs to put his hand through the fibrosis. It is difficult for him/her to distinguish the bladder from the prostate from the rectum. When a surgeon goes in to take the prostate out, he/she sees a large ball of scar tissue that the bladder, rectum, and prostate are in there somewhere. The tissue planes that allow you to separate one organ from another are obliterated. If you are aggressive in removing the prostate, you risk damaging the bladder or the rectum. This is what causes the high risk of incontinence and colostomies that you do not see with either prostatectomy or radiation alone. If you are not aggressive enough, then you risk leaving some prostate tissue behind. By staying away from the bladder and rectum, the tissue you leave behind is the tissue most likely to contain cancer, since it is in these regions that most cancers arise.

This is one of the reasons why I will sometimes recommend surgery to younger, very concerned patients – this way, there is one more arrow in the quiver. For low-risk prostate cancer, the 5-year bNED (biochemical no evidence of disease) survival is about 92% with radiation and about 80% with surgery. Radiation can salvage about 60% of surgical recurrences if caught early. 60% of 20% is 12%, so the overall cure rate with surgery is 80% with surgery + 12% with salvage RT=92%. I don't think there is a difference in cure rate between the two treatments, but it is a "peace of mind" issue for some patients to have a follow up option.

Jan 27, 2012 - Treatment with radiation therapy after excision of ductal carcinoma in situ in women age 60 is associated with a slight improvement in survival, but may increase the likelihood of eventual mastectomy, according to a study published in the Feb. 1 issue of Cancer.